Emergency Screening Form

Name *

Address *

Date of Birth *

Date

Phone Number *

Email

example@example.com

PPS Number

Please Select Which Dental Practice You Attend *

Dr. Padraig O'Reachtagain, Roscrea Previously a patient of Dr. Gerry Browne, Birr

Have you been advised by the HSE or your General Medical Practitioner to self-isolate? *

Yes No Other

In the past 14 days, have you had or do you currently have any of the following: *

High Temperature Shortness OfBreath/Difficulties Breathing Cough A Household contact of a Covid 19 Positive Patients Awaiting results of a PCR Test None of the above

Are you allergic to penicillin? *

Yes No Other

Are you allergic to any other medication? If soplease specify *

Yes No Other

Name of your pharmacy

Are you pregnant?

Yes No Maybe

The following are considered as dental emergencies, please select which applies to your current situation:

Swelling of face and/or neck associated with yourmouth Acute dental pain causing you not to sleep An accident or trauma which has caused the teeth to move preventing you from closing your teeth I don't have an emergency, can you please call me back

Please specify the nature of your emergency and any other additional information we should be made aware of including illnesses and current medication:

Please specify the location of pain / broken tooth/ trauma:

Top jaw Bottom jaw Left side of your face Right side of your face Towards back of your mouth Towards front of your mouth Other

Is the tooth

Painful to touch or bite on Sensitive to cold Sensitive to hot Cutting your tongue Other

Upload a picture. i.e. broken tooth / swelling etc. (Optional)

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